Concussion Recovery, And Should Headers In Soccer Be Banned?


Welcome to Better Brain Fitness, hosted by doctors Josh Turknett and Tommy Wood. In this podcast, we will explore the frontiers of how to keep our brain fit and healthy so that we can perform at our best and do the things we love for as long as possible. Let’s go. Ok, welcome to another episode of Better Brain Fitness. I’m joined today by my special Co host, Dr tommy Wood hello tommy hello. So today’s question we are going to be asking the esteemed Dr wood to try to answer.

00:41 : It comes from Zhao and it’s related to the topic of concussions, he says i’ve been working in football or soccer for 20 years and we can see now an increased interest and awareness regarding repetitive concussion and the potential contribution to brain disease in the following decades of life. Most of the football authorities, including FIFA, are trying to find solutions and in UK there’s been a discussion regarding limiting heading the ball in younger ages. Do we have enough data to be aggressive in our intervention? What is the science showing us at the moment? So that’s a excellent question, a hot topic, probably one that a lot of parents think about and certainly anyone more broadly has any history of concussion or head trauma and the risk of what that means for, you know, brain health over the course of time so tell me what do you think, what’s the data show? It’s a it’s a great question and one where you could come at it from two different directions because in reality the data probably aren’t good enough to say that we know the answer however, when you’re trying to look for or trying to do the best by particularly younger kids and their longterm outcomes maybe it’s is worth erring on the on the side of caution.

02:10 : So I’ll talk briefed about this and then i’ll give a little overview about how I think about concussion recovery and then maybe that will stimulate some future questions we can certainly dig into things a little bit more, but there have been a few studies now that try and answer this question and more broadly, let’s say that there is an even robust scientific consensus that says that multiple concussions or even sub concussive exposures definitely contribute to neurodegenerative disease but I personally feel like the data are compelling enough that we should be intervening.

02:53 : There are political reasons why some people feel like the evidence is isn’t high enough, however, particularly from American football players and the types of pathologies we see on later, you know, brain slices and some of the symptoms that they get. Either there’s this idea of something called chronic traumatic encephalopathy or CTE, and there are more and more rugby players, you know, bringing this to light longterm cognitive dysfunction or cognitive decline in professional rug players and then soccer players and football or football, real football players as well so I think that there are enough data to suggest that there is something inherent in this process of repeated small impacts to the brain are having a long term effect on cognitive function and risk of dementia in professional football players.

04:00 : There are two studies that have looked at this one was published in German urology 2 years ago looking at Scottish professional football players, and then one just came out in Lancet Public Health a couple of months ago in Swedish professional football players. And both found the same thing, which is that there was a compared to population controls, there was an elevated risk of dementia in those who formally played professional football in outfield players but not goalkeepers. And both studies found the same thing and that’s interesting because goalkeepers rarely if ever had the ball whereas the a lot of outfield players do it depends, you know, maybe the strikers and some defenders do more but you know there is, there is certainly much more heading it’s much more frequent in outfield players.

04:48 : Nobody has yet been able to say you know total number of headers and that kind of stuff and looking at where there’s a dose response which we would expect, which we would certainly expect there to be in some regard but it does seem that there’s some signal in the data there. At the same time, we know that concussions are very common in youth sports that’s where are, you know, the question originated.

05:14 : And in youth soccer players over here in the US there are probably hundreds of thousands if not millions of concussions every year and maybe if you’re thinking about then headers and other things that don’t result in a loss of consciousness or this or an overt change in function but could still be affecting the brain, you know, you’re talking large numbers of very large numbers of kids who are potentially being affected. And when we then think about trying to implement some kind of systemic change to how the game is played, particularly in kids, I think it is worth considering, you know minimizing heading the ball at a younger at younger ages for two main reasons one being that the cumulative exposure over a lifetime, particularly these kids go on to play in college or maybe even professionally.

06:17 : You know that that’s something that we do need to take into consideration but also the concussions that do happen most frequently either because you know you’re heading the ball itself or you’re heading somebody else’s head while you both try and head of the ball. That’s when a lot of concussions happened my wife played soccer at a very high level, including at college and she had a number of quite serious concussions and that was the scenario that usually led to them. And in terms of the risk of the brain or the risk for the brain, there is an aspect of how strong the rest of the body is that provides some degree of protection.

07:04 : So you know, in sports where both men and women play, you know, on average men are stronger than women. There’s overlap of course, but in general men have more muscle mass around the neck than women do. Of the same, you know, age and experience with the sport and neck strength seems to be protective. So the younger you are, the less trained you are, the less strong your neck is, the less protection you have from a physical, structural standpoint.

07:40 : And that’s going to be the most relevant in kids. So I think there are a number of reasons why we might consider even if there isn’t great data saying yes headers and kids are definitely going to cause long term dementia risk. We though we haven’t been thinking about it long enough for us to look at how much kids are heading the ball and even getting good reporting data to then look 60 years into the future to see whether they get an increased risk of dementia we just like not that’s not a timeline or research study that anybody’s able to design or run yet and I imagine those things will be done but at this point I would still say I think we could be cautious enough to try and minimize those high risk situations where concussions are more likely to happen and or even those repetitive impacts such as heading the ball in younger age groups because there may be a greater risk from the injury itself and then also you know they don’t have some of the protective factors in places as older individuals may and then you know they’re playing a much lower stakes games so maybe it’s just not worth the risk that’s probably what I would take away and I think that’s what that’s what the authorities have decided as well and i feel like that’s a sensible A sensible stance to take.

09:06 : If that doesn’t, if JAO, if that doesn’t answer your question then let me know and then we can dig into that even further. The next step is sort of what do we do in a scenario where something like that occurs. And I’ve even worked with some military groups where you know and they’ve showed me some data that suggests that very small impacts or exposures that you couldn’t detect in any meaningful way in the moment can accumulate over time so if you’re firing a sniper rifle which is essentially setting off a mini explosion next to your head every time you do it and you’re practicing on the range and then maybe go out into the operating field and you’re doing that in real in a real life situation.

10:00 : Those explosions happening next to your head, even though each one you couldn’t detect an effect they do seem to be having an effect over time and there’s no reason to think that you know a really strong or force or head of the ball wouldn’t have some similar kind of kind of effect. And so I would expect these things to it to accumulate over time so when these kind of injuries do occur and you maybe don’t need to think about this every time your kid head is the ball but you’re specifically or and you know largely if some kind of significant concussive event occurs and there’s still debate as to like how you even define a concussion, like that’s part of the problem like what does it mean to be concussed.

10:51 : You know do you have to become you. It’s not that you have to become unconscious as people thought previously and probably a concussion is happening at the level of the brain, different cells in the brain, but you can’t even detect it. So there’s still there’s still debate on even what a concussion is. And so that’s why another reason why this is this is such a muddy field. However, there are a few things that i think we can take into account and that we can kind of use to you know mitigate some of these exposures so you know, i even get emails from parents who are like my kid plays the sport, they get concussions or they’ve gotten a concussion or there are risk of concussions like what? What can I even do? And you know I’ll preface this and saying this is not non medical advice, you should like work with your doctor, but I think there are some things that we can think about.

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12:18 : All right now back to the show. So the first is up to the point at which a concussion occurs i think we can. There are some things that we can consider nutritionally that may increase the resilience of the brain to an incoming impact so the first is creatine. Of course, that’s my answer to everything, and so the I did a whole episode previously on creatine you can go back and find that but there’s lots of compelling data to suggest that creatine can be increased in the brain with supplementation and that if you supplement prior to some kind of traumatic brain injury it is neuroprotective and creatine in the brain is also used up or you decrease the amount of creatine you have in the brain with successive impacts this was studied in high school American football players the more impacts that they had over a season the more there was a decrease in creatine in certain areas of the brain that they tested on MRI scan so I think we can mitigate a bunch of those things with the creatine choline is the is the same as it’s a part of the membranes in cells in the brain.

13:35 : We talked about this on a recent episode as well Creatine, the choline does seem to decrease in some areas of the brain, particularly the most cortex with successive impacts again this was done in high school football players and there is some randomized control trials that say that choline can improve recovery, particularly some psychological factors after a traumatic brain injury so reasons to consider coding intake before and after concussion same with creatine.

14:05 : Dha is another one. There was a study again looking at a youth American football players where they randomize them to different amounts of DHA the long chain omega three fatty acid, over the course of the season. And what they saw was it in those taking a relatively low dose of DHA it was 1 to 2 grams per day. They saw a decrease in the accumulation of a marker of neuronal injury that circulates in the blood called neurofilament light compared to placebo. So if you’re repeatedly in these situations where you’re getting the small impact, so say if you’re playing American football every snap has the potential to have some kind of jarring effect on the brain and these may accumulate over time and that was what they saw was that in the placebo group there was accumulation across the season of this marker of or potential marker of brain injury and that was reduced in the group taking DHA So just a small amount of fish oil or regular fish intake can help there.

15:10 : And then the final thing that I would consider is magnesium mainly for two main reasons magnesium intake is generally low in the population so 3 reasons it’s generally low in the population. Magnesium circulating magnesium levels correlate with both cognitive function and longterm dementia risk, and magnesium is an important factor when regulating the neurotransmission after some kind of acute neurological injury there’s this idea of something called excitotoxicity. Because you have this dysregulation of our neurons fire at the point of injury that then releases a whole bunch of excitatory amino acids that can over stimulate other neurons that can then cause mitochondrial dysfunction and in a the worst case scenario, even your own or death, Magnesium helps to regulate that process so particularly if people are, you know, not eating much magnesium, then magnesium is something to consider again, it’s very simple, very safe supplement that the people can take at the time of injury and after the injury temperature is incredibly important and this is actually what I did my PhD in is temperature and brain injury and there are multiple different studies both in animal models and humans that say that the core body temperature at or around the time of a brain injury affects long term recovery so if you’re hot then, and your brain is hot either during the impact or afterwards, you get a fever in response to the injury, which is very common, and we get some kind of injury, we get a fever that can then worsen the outcome.

16:56 : This is important for sports because sports injuries and concussions often happen in a heat stressed environment. You’re already hot, you’re running around, maybe you’re outside and it’s sunny, maybe you’re on a field in a stadium and it’s sort of like the temperature down on the pitch can be much higher than it is in the stands or outside just because of the nature of how the stadium is built. So there are strategies to maintain a normal cool body temperature so if I’m working with certain groups, there are high risk of a concussion on a sports field and it’s hot, then things like precooling, like getting in a cold water before playing or wearing some kind of ice fest before they get on the pitch.

17:43 : That can decrease a body temperature, you know, by like half a degree Celsius or 1 degree Celsius. That actually improves performance it increases time to fatigue and then may also keep your brain, you know, in a slightly better state. If you do end up getting a concussion after a concussion, then making sure that you don’t, that you control a fever is really important. So for the next two or three days afterwards there’s a likelihood, particularly you know the more severe the injury, the more like you are to get some kind of big immune response and some kind of fever.

18:18 : And so then things like you know, Tylenol or other anti fever medications can be beneficial as can just making sure you’re not, you know, overheating be that in terms of how you’re closed or other things you know, just keeping an eye on temperature and trying to mitigate or minimize fevers as much as possible. And then that becomes relevant again with the final thing that’s important which is return to exercise. So particularly in youth concussions, the evidence is better for graded return to exercise as soon as possible after a concussion so there have been a couple of randomized control trials where they either had kids just essentially be sedentary as they as they tried to recover from that concussion or where they did essentially 3 times a week, they did 20 to 30 minutes of a light aerobic exercise up to the they’re sort of personal tolerance so you don’t want to exercise to bring on symptoms, but you want to exercise at a level just below that.

19:29 : So in those studies, they actually did a test where they saw how hard you have to exercise to generate symptoms and then they had them do just a little bit less than that, but 20 to 30 minutes of light aerobic activity so this could be walking, brisk walking, cycling, something like that. Doing that seems to accelerate recovery, and there are a whole bunch of reasons why exercise you can help support the brain as it recovers. However, you have to balance that with the fact that if you exercise you can get hot.

20:00 : So again, just making sure that you’re not exercising in a heat, stressed or hot environment or. If you don’t have an option otherwise, then there are some athletes I’ve worked with where we’ve done things like you know, they’ve sat on an exercise bike but they’ve worn an ice fest or something like that just to like make sure that they’re not sending hot blood up to the brain as they do some exercise because it’s the body temperature naturally increases the exercise.

20:28 : Then the last thing to consider is, you know we haven’t talked about food after a concussion i think some of the supplements I mentioned are important, but I would also try and minimize large swings in blood sugar. There are several studies that again suggest that hyperglycemia, so high levels of blood sugar after an injury, after a brain injury and that can be concussion, stroke, you know a whole range of injuries seems to worsen the outcomes.

20:57 : Some of it is tricky to unpick because the more severe the injury, the more likely you are to have a big inflammatory response which then makes your blood sugar go higher so it’s part of it’s like what’s chicken and what’s the egg. But I think it’s worth saying that you’re minimizing foods that can cause big bikes in blood sugar is probably going to be a low risk thing that’s worth considering so as you are wheeled off the pitch with your concussion, don’t drink the Gatorade or anything like that, which is very common like i would avoid those, you know, sugary drinks or anything like that and just try and minimize your refined carbohydrates, in particular cakes and sweets and things like that in the few days afterwards, just try and keep blood sugar more stable, You know, focus on more Whole Foods and you know, protein and maybe a little bit of seafood, right you get your DHA, some meat, get your creatine, some eggs, get your choline.

21:54 : All of those things will also be you know less will have less of an effect on your on your blood sugar which is probably again I don’t have high level evidence to suggest it but it’s going to be a low risk thing that could have could have some benefit so those are kind of the things that I think everybody can do or you should think about in terms of concussion, how I think about concussion recovery. Great i’ve got a few little follow up questions for you. So one would be I know that there’s good data on hypothermia after hypoxic, ischemic injuries and that’s now kind of routinely done in the hospital bringing down core body temperature.

22:44 : I know there’s been some research into that concept with concussions and head trauma and I know there’s I think they were developing some cooling helmets or things like that. Do you know any is that does that approach look to be promising in that domain? No OK. And this is one of the interesting thing, the things has been interesting to follow along over the past few years and there is they could yet still be a breakthrough however, you’re right the SO the one specific type of brain injury that i work with in the lab is a neonatal brain injury that happens around birth.

23:28 : The current standard of care is that you cool those babies down for three days immediately immediately afterwards, and you need to start very soon, you know as soon as you can with the injury and that’s probably the case for any kind of cooling strategy, for any acute brain injury, for other brain injuries, pediatric traumatic brain injury, adult traumatic brain injury, pediatric and adult out of hospital, cardiac arrest adults, ischemic stroke, You know all of those have very similar components and acute loss of blood flow and oxygen to the brain. And then in animal studies, cooling, you know, hypothermia, cooling the brain down or the body down for one to three days afterwards works really well.

24:17 : Dozens of randomized control trials in humans have failed to show any benefit in all of those scenarios. And people, you know, that there are some reasons why that might be the case that are purely due to how difficult it is to run a randomized control trial so you need to start hypothermia as soon as you can, right if you wait four or five hours, it’s too late. So that could be one of, well, that could be one of the issues and then also in some of the adult trials in particular, they might only cool for 24 hours when maybe you need to cool for several days.

24:52 : So some people argue that it would still work if we did the right protocol, but there’s no evidence to suggest that that’s the case to be honest. A lot of hospitals do it. So if there’s an out hospital cardiac arrest in an adult, they will, you know often hospitals will have a cooling protocol for you know some number of days afterwards. I don’t think the evidence is great to support that, but I also don’t think there’s any risk in doing it necessarily by a very talented intensive care specialist team who know what they’re doing fine.

25:27 : However, if you look at the totality of evidence, I think the most important thing and they’ve done more of this recently is what we call targeted temperature management so what it is essentially preventing a fever, which is what I which is what I talked about. So in the really good clinical trials, they compare an active hypothermia state to a targeted temperature management state so you’re preventing fevers in the control group. Historically some of the studies that show a benefit of hypothermia, they didn’t do that in the control group got a bunch of fevers, so they were allowed to get hot.

26:06 : And so then it’s difficult to figure out, is it that the hypothermia is beneficial or is it that the fevers are bad in the control group? And in studies where they have targeted temperature management in the control group, that doesn’t seem to be much of A benefit of hypothermia so I think most of the benefit of hypothermia is actually because you’re preventing fevers rather than because it’s beneficial to be actively cold, if that makes sense i think that’s kind of where we’re, that’s kind of where we’ve landed with most of the evidence across those range of brain injuries cool.

26:39 : It’s interesting too that that’s kind of if we can put this back into the demand coupling concept and the idea of stimulus and support and with I think one of the, I think big takeaways here is that after a concussion, after a brain injury, you know, you want to be focusing heavily on the support side, right and you So that is that is a stimulus it’s going to be, you know, increasing repair and recovery mechanisms in that particular area so you want to make sure you’re doing all that you can, but by the same token you just mentioned the data that showing that you don’t want to do nothing in that intervening period you know you want to kind of find that threshold of activity but since we know and as we’ve talked about you know cognitive activity, physical activity also drives repair and recovery that can help up regulate those mechanisms even though you might be inclined to think you want to do nothing.

27:31 : So that that’s interesting how that how that fits in in this scenario as well. It also like I think one of the open questions and I didn’t know if you knew of any animal models that answer this at all. But whether or not the how much of the you know subsequent complications like CTE from a head injury are related to either sort of just the extent of the initial injury and how much is related to actually the recovery process so could you, could we conceivably mitigate most or all issues in a majority of cases simply by getting better at how we support the recovery process.

28:13 : Do you know of any animal data? Yeah, no and there’s several reasons why those animal studies have not been done it would be very difficult to do and some of it is relates to how we study brain injuries in animal models so the vast majority of animal models of brain trauma are not relevant to most cases of human brain trauma or concussion. What they do and there are several different ways to do this what they do is they essentially open the skull and then they bash something against directly against the brain.

28:56 : That is not how the brain gets injured unless you have penetrating brain trauma. And actually the mechanisms in the areas of the brain that get affected are very different in that in the in the actual human scenario. So first of all those models aren’t relevant to humans second of all, you can’t do multiple repeated injuries over time with that kind of model because you’ve opened the skull, you know you can’t keep hitting an injured part of the brain. So there are some models that have a closed, you know, closed skull as you should. You know if you’re trying to model a concussion and you can give repetitive impacts.

29:38 : The problem is that most people or most groups might only do two or three repeat exposures and you may separate them by 24 hours or by a week. The some trickiness and trying to figure out what would you do in an animal to model the number and accumulation of exposures in a in a career of say a human athlete. Nobody is doing anything like that and then on top of that, when you know it most again researchers in the field are probably not studying how to optimize recovery with say supplementation plus activity plus cognitive activity plus so there are just a whole bunch of variables that make it very difficult to try and figure that out.

30:34 : My guess is you can mitigate a lot of it, maybe not all of it but a lot of it. However, i’m just I’m just guessing i don’t think there’s good evidence to support them. I would I would think that even and totally the, you know the issue of being able to have a an animal model that actually replicates in any way what’s happening in humans is really challenging and this you know probably never going to have one that’s fits the bill in this category but that being said, I think it would still be useful to even in the in the you know models that exist to know just as proof of concept how much variation you can get by attending to recovery processes you know.

31:22 : Well that’s something that I’m working on myself but I might not have that answer for several years. So I have a closed head you do okay type model it that I developed in the lab. I think it’s very relevant to the human scenario or at least much closer than lots of other models. However, the time and money it would take to do a really long term study there is quite substantial.

31:50 : So yeah, still work on it. Well, good i’m glad you’re on it. It’s a couple of final little points. One you mentioned the about the diagnosing concussion i think one of the most common myths out there is how that actually happens it is still a clinical diagnosis you’ll, I hear it go all the time saying that he’s going to get the they’re going to get the CAT scan to see if it was a concussion. And like no, it’s actually still just a clinical diagnosis Also definitely shouldn’t be a CAT scan you’re not gonna see anything no but trust me, even a very fancy MRI is gonna struggle.

32:30 : No, you’re not gonna say anything i mean conceivably they’re just doing that to rule out of bleed, but it has nothing to do with the concussion diagnosis whatsoever. So I will say that there’s some interesting work being done in the quantitative EEG space. There’s something called brain vital signs, which is basically you have a very simple set of electrodes that you put on the skull that they have a sort of a consumer or at least a, you know, an accessible version that teams, sports teams and things can use. And then what they do is they give you very specific stimuli so an auditory stimulus and then you look at how that gets responded to in the in the brain in terms of the timing and some of the frequencies of the EEG and you would ideally have baseline in these individuals and you and you can see that this changes with concussions and then you can you can see how it improves with recovery and there are some preliminary studies that suggest if you if you do you know some kind of concussion protocol or graded exercise protocol that you can accelerate improvements so there’s nothing there i would say this is what definitely what we should do but I think we’re getting we’re getting better at developing or leveraging technology to pick up some of these subtle changes that happen in that scenario so hopefully that will that will become more common in the next few years.

33:59 : Yeah I think that’s very promising technology especially coupled with machine learning and so forth much more so than what we have with imaging. And then one last thing i did look up to date on concussion by sports and for what it’s worth 1-1 study here was showing that in youth sports the highest concussion rate was in is in rugby that actually fairly substantially higher than the others. Ice hockey came in second, followed by American football, lacrosse, then soccer.

34:38 : Those were the top five and then in, let’s see, the adults. Number one was still rugby, but not quite as much, Just over American football. Then women’s ice hockey, then men’s ice hockey, then women’s soccer. So interesting, although I do I don’t know if it’s, I do recall there was data showing that the actual severity of concussions in American football was greater than in rugby. But right now, all right well we have a lot more people a lot more people play rugby than these are by like they’re normalized they’re normalized to a thousand you know rate per a thousand games or something like that.

35:16 : So okay well that was great overview of this topic lots of stuff there and if you have any followup questions, please feel free to ask us go to So thank you all for listening and we will see you next time thanks, Tommy.